Granulomatous Pneumonia and Liver Lesions Associated With Crohn’s Disease

To the Editors, A 26-year-old man with Crohn’s disease (CD) presented to our hospital with a 3-day history of fever, cough, fatigue, nausea, and vomiting. The maximum temperature was 102.2°F. Crohn’s disease had been diagnosed 10 days previously based on abdominal pain, diarrhea, and ileocolic ulcerations at ileocolonoscopy with histology revealing chronic inflammatory changes and characteristic granulomas in the terminal ileum. However, no medication was given due to obscure pulmonary nodules involving the right upper lobe. Physical examination on admission was normal. Relevant laboratory values on admission revealed moderate increase of white blood count (12070/μL), erythrocyte sedimentation rate (59mm/h), and C-reactive protein level (73.47mg/L). Computed tomography (CT) scan of the chest and abdomen revealed multiple bilateral patchy and nodular consolidations and patchy ground-glass opacities in the left lower lobe (Figure 1A), and several round, dense lesions in the liver at portal vein phase, with the maximum size of 9×8mm (Figure 1E). The patient was empirically started on intravenous moxifloxacin for presumed bacterial pneumonia after obtaining blood cultures. During the course of his hospital stay, the patient was unresponsive to antibiotic therapy but progressed to worsening bilateral lesions, especially in the left lower lobe (Figure 1B), which required further fiberoptic bronchoscopy and lung biopsy. The laboratory workup including ANA, DsDNA, lymphocyte markers, immunoglobulins, virus serological examinations, mycoplasma titers, and Legionella antigen was all normal. Tuberculin skin test, interferon-gamma release assay (IGRA), acid fast stain test of sputum smear, and QuantiFERON-TB Gold In-Tube tests for tuberculosis were negative. All his blood and sputum cultures for bacteria, virus, and fungi were negative. Bronchial brush samples were negative for malignant cells. Specimens from CT-guided percutaneous needle lung biopsy revealed focal inflammatory infiltrate without granulomas.